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Contact Information

Last Name
*
First Name
*
Street Address
*
Street Address(2)
City
*
State
*
Zip Code
*
Home Phone
*
Work Phone
*
Fax Number
*
Email
*
How did you first hear about Results Personal Fitness Training?
*
If referral, please provide the name of the person who referred you
*

Health History Questionnaire

Are you a male and over the age of 40, or a female and over the age of 50?
Yes No
Have you had any pain or discomfort in your chest area?
Yes No
Do you ever have dizzy spells or feel faint?
Yes No
Have you been diagnosed with diabetes?
Yes No
Has your doctor told you that you have a heart condition?
Yes No
Have you been diagnosed with emphysema, asthma or bronchitis?
Yes No
Have you ever had a thyroid problem?
Yes No
Are you pregnant?
Yes No
Has your doctor told you that you have high blood pressure?
Yes No
Have your parents or siblings suffered from heart disease prior to the age of 55?
Yes No
Are you a cigarette smoker or were you in the last six months?
Yes No
Has your doctor told you that you have high cholesterol?
Yes No
Physician Name
*
Physician Phone
*
Physician Address
*

Fitness Priorities

Please review all of the following statements, then check the box next to the statement that best describes what you are looking for from RESULTS Personal Fitness Training.

I am new to exercise and would like to learn the essential elements of a safe and effective fitness program so that I can workout on my own.

I am new to exercise and would like to learn the essential elements of a safe and effective exercise program. Once I've learned the basics, I would like to continue to periodically work with a trainer to keep my program fresh and challenging as my fitness level advances.

I used to be physically active and am seeking help and support in getting back into a regular fitness program. Once I'm back on track, I'd like to periodically work with a trainer to keep me focused and motivated.

I am currently exercising, but would like some expert guidance in refining my program and technique so that I can safely achieve my fitness goals in the shortest amount of time possible. I am actively involved in a specific sport and want to bring my performance to the highest level possible. Sport:

Fitness Goals

Using the following scale, please rate the importance to you of each of the following benefits of fitness:

1= a top priority
2= very important
3= important
4= nice, but not a priority
5= not important to me now

Weight Control
1 2 3 4 5
Decrease Body Fat
1 2 3 4 5
Improve Athletic Performance
1 2 3 4 5
Improve Flexibility
1 2 3 4 5
Increase Energy
1 2 3 4 5
Increase Lean Muscle
1 2 3 4 5
Increase Calorie Expenditure
1 2 3 4 5
Increase Metabolic Rate
1 2 3 4 5
Prevent Lower Back Pain
1 2 3 4 5
Prevent Injury
1 2 3 4 5 *
Improve Heart Muscle Strength
1 2 3 4 5
Improve Posture
1 2 3 4 5
Reduce Risk of Heart Disease
1 2 3 4 5
Firm & Tone Body
1 2 3 4 5
Strengthen Immune System
1 2 3 4 5
Increase Strength
1 2 3 4 5
Reduce Risk of Osteoporosis
1 2 3 4 5
Stress Management
1 2 3 4 5
Increase Stamina & Endurance
1 2 3 4 5
Increase Bone Strength
1 2 3 4 5
Reduce Cholesterol Levels
1 2 3 4 5		  

 

Please press this button to save your profile:


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Send mail to resultspft@rcn.com with questions or comments about this web site.
Copyright © 2001 The Next Level.  All rights reserved
Last modified: November 02, 2003

 

Please note:  Information posted on this website is not medical advice and is provided for general information purposes only.  Seek the advice of a qualified health professional for medical advice and treatment.  Persons over 50 and anyone with a history of medical problems should consult their physician prior to beginning an exercise program.

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Send mail to resultspft@rcn.com with questions or comments about this web site.
Copyright © 2001 The Next Level.  All rights reserved
Last modified: April 25, 2006